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Quality Improvements in the Electronic Medical Record of Patients Treated with High Dose-Rate Brachytherapy

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T Diener

T Diener1*, D Wilkinson2 , (1) Cleveland State University, Cleveland, OH, (2) Cleveland Clinic Foundation, Cleveland, OH


SU-F-T-234 (Sunday, July 31, 2016) 3:00 PM - 6:00 PM Room: Exhibit Hall

Purpose:To improve workflow efficiency and patient safety by assessing the quality control documentation for HDR brachytherapy within our Electronic Medical Record System (Mosaiq).

Methods: A list of parameters based on NRC regulations, our quality management program (QMP), recommendations of the ACR and the American Brachytherapy Society, and HDR treatment planning risks identified in our previous FMEA study was made. Next, the parameter entries were classified according to the type of data input—manual, electronic, or both. Manual entry included the electronic Brachytherapy Treatment Record (BTR) and pre-treatment Mosaiq Assessments list. Oncentra Treatment Reports (OTR) from the Oncentra Treatment Control System constituted the electronic data. The OTR includes a Pre-treatment Report for each fraction, and a Treatment Summary Report at the completion of treatment. Each entry was then examined for appropriateness and completeness of data; adjustments and additions as necessary were then made.

Results: Ten out of twenty-one recorded treatment parameters were identified to be documented within both the BTR and OTR. Of these ten redundancies, eight were changed from recorded values to a simple checklist in the BTR to avoid recording errors. The other redundancies were kept in both documents due to their value to ensuring patient safety. An edit was made to the current BTR quality assessment; this change revises the definition of a medical event in accordance with ODH Regulation 3701:1-58-101. One addition was made to the current QMP documents regarding HDR. This addition requires a physician to be present through the duration of HDR treatment in accordance with ODH Regulation 3701:1-58-59; Paragraph (F); Section (2); Subsection (a).

Conclusion: Careful examination of HDR documentation that originates from different sources can help to improve the accuracy and reliability of the documents. In addition, there may be a small improvement in efficiency due to elimination of unnecessary redundancies.

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